Provider Demographics
NPI:1659524494
Name:STAYTON FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:STAYTON FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:B
Authorized Official - Last Name:LARGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-769-2641
Mailing Address - Street 1:1375 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-2037
Mailing Address - Country:US
Mailing Address - Phone:503-769-2641
Mailing Address - Fax:503-769-3797
Practice Address - Street 1:1375 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-2037
Practice Address - Country:US
Practice Address - Phone:503-769-2641
Practice Address - Fax:503-769-3797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-24
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty